35 YEAR OLD FEMALE WITH FEVER AND SEVERE HEADACHE
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CASE PRESENTATION
I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan .
A 35 year old female resident of nakrekal who is a house maker by occupation came with
Chief complaints-
1.Fever since 1 week
2.Headache since 1 week
History of presenting illness-
Patient was apparently asymtomatic 10 year back then she developed unexplained weight gain and fatigue for which she went to local hospital where she found to be Hypothyroidism and she was on thyroxine medication.
1 week back then she developed fever which is intermittent in onset,increasing at night time and decreasing in the morning(on and off) ,associated with chills and headache.
Fever is relieved by taking antipyretic.
No history of Nausea,vomiting,rash or body pain.
History of unilateral headache since 1 week which is severe throbbing type in left fronto parietal occipital region radiating to the neck,it is aggravated on exposure to stress.Headache makes her wake up abruptly in the night leading to inadequate sleep.
Headache is associated with vomiting(just 1 episode),blurring of vision(history of change in spectacles),decreased regular physical activity,tingling sensation in hand and feet.It relieves on taking rest and medication.
No history of aura,photophobia,depression,irritability,cravings,diarrhoea/constipation.
She has history of burning micturition since 5 days associated with decreased urine output,decreased frequency,left loin pain which is dragging type pain(since 2 days).No aggravating and relieving factors.No history of urgency,hematuria,nausea,vomiting.
Daily routine-
She gets up at around 5 AM in the morning , does her daily chores and helps her children get ready for school.
She has her breakfast at 8.30 AM in the morning and then sleeps for sometime before preparing and eating lunch by 2 pm.
She spends rest of her day by watching TV or doing daily chores.
She used to work as a daily wage labourer before 6 years.
She prepares dinner and eat at 9:00AM and sleeps by 9:30
PAST HISTORY-
Not a known case of diabetes mellitus,hypertension,epilepsy,cardiovascular disease and tuberculosis.
History of hypothyroidism 10 years back.She was taking 50 mg thyroxine supplements until 2 years before when she had few episodes of lethargy and she had to consult a local doctor who investigated her thyroid profile and increased thyroxine dose to 75 mg thyroxine supplements.
History of renal stones in the left kidney 6 years back for which she took some conservative treatment.
Family history-
No significant family history.
Personal history-
Diet: mixed
Appetite: decreased
Sleep: Inadequate
Bowel and bladder: constipated
Addictions: none
No H/O of any drug allergy.
General examination-
Patient is conscious,coherent and cooperative.Well oriented to time,place and person,Moderately built and nourished.
Pallor-present
Icterus - absent
Clubbing - Absent
Cyanosis- Absent
Lymphadenopathy- absent
Edema - absent.
Fever chart-
Vitals:
Temperature-99 F
PR-84 bpm
RR-20 cpm
BP-100/70 mm of Hg
Systemic examination:
CVS- S1 S2 heard,no murmurs present.
RESPIRATORY- bilateral Air entry present
Normal vesicular breath sounds heard
Examination of oral cavity - normal
CNS-no focal Neurological deficits
HIGHER MENTAL FUNCTION
Counsious ,oreinted to time place person
Speech normal
Behaviour normal
Memory intact
Intelligence normal
MENINIGEAL SIGNS-
No neck stiffness
Brudzinski’s sign-negative
Kernig’s sign- negative
SENSORY SYSTEM - normal
Per ABDOMEN- soft , tenderness in present (mild in epigastrium
Inspection:
Shape-normal (rounded)
No flank fullness is seen
Skin-no scars seen,presence of striae
No dilated veins seen
Movements of abdominal wall-no visible peristalsis,no visible pulsations
Umbilicus-inverted
Palpation -
No tenderness
Warmth-present(fever)
Rigidity,guarding is absent
No organomegaly,normal bowel sounds heard
Percussion -
No shifting dullness , fluid thrill
Auscultation -
Bowel sounds heard
Provisional diagnosis:-
Migraine/left renal calculi/UTI
Investigations:
Complete urine examination:
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